John Kao

Factors Associated With Off-Label Use of Drug-Eluting Stents in Patients With ST-Elevation Myocardial Infarction

Drug-eluting stents (DESs) are used in >80% of percutaneous coronary intervention (PCI) procedures; however, up to 2/3 are used for off-label indications. Factors associated with DES use in patients with ST-elevation myocardial infarction (STEMI) are not known in contemporary clinical practice. We analyzed temporal trends, geographic patterns, and sociodemographic factors associated with off-label use of DESs in patients undergoing primary PCI for STEMI from July 2004 to March 2006 in the National Cardiovascular Data Registry (NCDR). The main outcome of this study was receipt of any DES, and the candidate independent variables were sociodemographic, hospital, clinical, and procedural variables. We also analyzed temporal trends and geographic patterns for use of DESs. A total of 30,235 patients with STEMI underwent primary PCI with use of DESs (84%) or bare metal stents (16%). Adoption of DESs was rapid but varied widely as a function of geographic location. After adjusting for clinical and procedural variables, older age was associated with lower use (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.91 to 0.98), whereas white race (OR 1.14, 95% CI 1.03 to 1.27), commercial insurance (OR 1.22, 95% CI 1.11 to 1.34), and the west census region (OR 1.37, 95% CI 1.04 to 1.81) were associated with higher use of DESs. In conclusion, adoption of DESs was rapid in patients with STEMI, but geographic location and sociodemographic and hospital factors were associated with the use DESs.

Direct thrombin inhibition appears to be a safe and effective anticoagulant for percutaneous bypass graft interventions

Background: Percutaneous coronary interventions (PCI) of coronary artery bypass grafts (CABG) are associated with worse outcomes compared with those of native coronary PCI. Little is known concerning the use of direct thrombin inhibition during CABG intervention. The objective of this report is to examine the safety and efficacy of bivalirudin with GPIIb/IIIa blockade inhibition in patients undergoing CABG PCI. GP IIb/IIIa use was provisional in REPLACE‐2 and planned in REPLACE‐1. Methods and Results: A post hoc analysis of patients undergoing CABG PCI in the REPLACE‐1 and ‐2 trials was performed. In REPLACE‐1, patients were randomized to either heparin or bivalirudin, with GP IIb/IIIa inhibitor use at the operators discretion. In REPLACE‐2, patients were randomized to heparin plus GP IIb/IIIa inhibition versus bivalirudin with provisional GP IIb/IIIa blockade. In both studies, randomized treatment groups were well matched. In unadjusted and logistic regression analysis, there were no significant differences in the combined endpoint of death, myocardial infarction, urgent revascularization, or major bleeding when patients were treated with either heparin or bivalirudin. Individual safety and efficacy endpoints were also similar. Minor bleeding was significantly reduced in patients treated with bivalirudin (14.8% vs. 22.7%, P = 0.037). Follow‐up data available from the REPLACE‐2 trial at 12 months found similar efficacy between groups with a trend towards decreased 12 month mortality in the bivalirudin vs. heparin groups (4.2% vs. 7.8%, P = 0.16).CONCLUSION: CABG PCI using bivalirudin with provisional GPIIb/IIIa inhibition appears to provide similar safety and efficacy to heparin with GPIIb/IIIa inhibition.

Tricuspid Regurgitation Causing a Right to Left Interatrial Shunt with Normal Pulmonary Pressures

We describe a patient who presented with asymptomatic hypoxia refractory to supplemental oxygen. Transthoracic echocardiography and angiography demonstrated a tricuspid valve with a large regurgitant jet oriented directly at a patent foramen ovale, producing a right to left shunt with systemic hypoxia. The patient was found to have normal right-sided cardiac pressures as well as normal pulmonary arterial pressures, demonstrating the shunt was secondary to the tricuspid regurgitant jet and not a result of a pressure gradient between atria. Surgical correction of the tricuspid valve and closure of the patent foramen ovale resulted in resolution of the patient’s hypoxemia.

Hospitals with percutaneous coronary intervention capability have greater adherence to established myocardial infarction guidelines.

Abstract The American College of Cardiology/American Heart Association guidelines for acute myocardial infarction related to process of care aim to decrease morbidity and mortality and provide a standard of care for patients with acute myocardial infarction (AMI). Currently, there are limited data comparing adherence between centers providing fibrinolytic therapy alone and those that provide percutaneous coronary intervention (PCI). Reported compliance with AMI performance measures was analyzed using data from the United States Department of Health and Human Services Hospital Compare Web site from 2007, including aspirin administration, β-blocker administration, angiotensin-converting enzyme or angiotensin receptor blocking agents, and smoking cessation counseling. Adherence to all reported measurements was significantly higher (P < 0.0001) in hospitals that reported PCI capability, compared with hospitals that reported only fibrinolytic use in AMI patients.